Supporting Statement 0960-0772

Supporting Statement for Form SSA-5072

Request for Medical Treatment in an SSA Employee Health Facility:

Patient Self-Administered or Staff-Administered Care

OMB No. 0960-0772

1. Justification

1. Introduction/Authoring Laws and Regulations

5 USC 7901 of the United States Code allows for the establishment of contracted health service programs within governmental agencies. In 1965, the Bureau of Budget Circular A-72 formerly established the policy that all Executive Branch agencies could establish preventative health services programs for their employees. State Nurse Practice Acts govern the practice and licensure of registered nurses. A state’s Nurse Practice Act sets out the scope, responsibilities, and limitations of nursing practice in that state. Although the scope of nursing may vary from state to state, all states require nurses to act under the supervision of a physician when performing certain duties, such as the administration of prescription medications. When the physician is not present, the Nurse Practice Acts require the nurse to follow the physician’s written orders in the administration of treatments and medications.

2. Description of Collection

SSA’s Employee Health Clinic (EHC) provides emergency care, treatment, of on-the-job illnesses and injuries, and health care for employees with chronic medical conditions and allergies who require allergy antigens. SSA also permits employees to use the EHC for self-administration of medical treatments for a chronic health condition. SSA collects information on Form SSA-5072 to approve or deny requests for medical treatment in an SSA EHC. The respondents are the private physicians of the SSA employees seeking medical treatment in an SSA EHC.

3. Use of Information Technology to Collect the Information

Form SSA-5072 is available on the SSA intranet as a printable PDF. Employees bring the form to their personal physician for completion and signature, and then return it to the Office of the Medical Director for review by the medical director. SSA did not create an electronic version of Form SSA-5072 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 100 respondents complete the form. This is less than the GPEA cut-off of 50,000.

4. Why We Cannot Use Duplicate Information

The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does affect small businesses or other entities. Some of the respondents may be self-employed physicians who have their own practices, or may be part of a small practice. We minimized the burden by carefully reviewing the form and only requesting specific limited information necessary in keeping with safe medical practices.

6. Consequence of Not Collecting Information or Collecting it Less Frequently If we did not collect this information, SSA would be unable to offer our employees the benefit of personal medical treatment and medication administration in our EHCs. Thus, employees would be required to take more sick leave to visit their doctor or allergist two or three times per week. Other employees would be required to either stay home from work to self-treat or find a less suitable, unhygienic place within the building to do self-treatment. If a participating employee’s medical condition, treatment, or medication orders change, the employee takes the form back to the physician to have the information updated. This could, but is not likely to be, monthly. Because we collect the information annually and bi-annually, we cannot collect it less frequently.

There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

If a participating employee’s medical condition, treatment, or medication orders changes, the employee takes the form back to the physician to have the information updated.

8. Solicitation of Public Comment and Other Consultations with the Public

SSA published the 60-day advance Federal Register Notice on February 10, 2014, at 79 FR 7736, and there were no public comments. We published the 30-day Federal Register Notice on April 23, 2014, at 79 FR 22752. If we receive any public comments, we will forward them to OMB. There have been no consultations with members of the public.

9. Payment or Gifts to Respondents

SSA does not provide payment or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

SSA uses Form SSA-5072 to collect medical information regarding an employee’s request to have personal medical treatment in the SSA EHC. This information is the basis for the employee’s request and for the Medical Director’s decision-making regarding the applicant’s eligibility for using the EHC for personal medical treatment or medication administration. Even though we must collect potentially sensitive medical information, we take measures to secure and protect it, and only necessary personnel have access to it. Without this information, the SSA EHC would be unable to honor the applicant’s request.

12. Estimates of Public Reporting Burden

Modality of Collection	Number of Respondents	Frequency of Response	Number of Responses	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-5072 Annually	25	1	25	5	2
SSA-5072 Bi-Annually	75	2	150	5	13
Totals	150				15

The total burden for this information collection request is 15 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $780. This estimate is a projection of the costs for printing the collection instrument.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirement at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical methods

SSA does not use statistical methods for this information collection.